Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Health Assessment > Nursing Diagnosis > Flashcards

Nursing Diagnosis Flashcards

1
Q

Three levels of care planning prioritization

A

1- ABC’s (airway, breathing, circulation)
2- Mental Status Changes; Acute pain
3- Unrelated health issues

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What does prioritization mean?

A

Deciding which needs require urgent attention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Questions you should ask yourself while prioritizing

A
  • What action will change the patient’s status right away?
  • Is the task life threatening?
  • Would another client be in danger if a task was left for later?
  • Is the task essential to patient safety?
  • Is the task essential to the client’s goals?
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

3 Components of care planning:

A

1- Identify priority problem
2- Provide etiology of problem
3- List the symptoms (subjective) and the cues (objective)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

3 Elements of a care plan nursing goal:

A
  • Simple
  • Time limited
  • Measureable
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Elements for nursing intervention

A
  • Determines elements of patient’s care for the day
  • Includes action items for nursing staff
  • Should be specific and able to be ‘checked off the list’
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Elements for nursing rationale

A
  • Determines ‘why’ we are listing interventions
  • Completes the circle of evidence-based practive
  • Should be scientific and based in evidence
  • Should be simple and concise
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

3 parts of the ear

A
  • External ear
  • Middle ear
  • Inner ear
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is included in the external ear?

A
  • Pinna
  • External auditory canal
  • Tympanic membrane (eardrum)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is included in the middle ear?

A
  • Malleus, incus, stapes

- Eustachian tube

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is included in the inner ear?

A

Lybyrinth
Vestibule
Semicircular canals
Cochlea

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Name for ear pain

A

Otalgia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What do we ask a patient when they have ear pain?

A 
Location
Character
Cold symptoms or sore throat
Injury or trauma
Alleviating factors
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Name for ear infection

A

Otitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What do we ask patients about ear infections?

A

Number (adult or child)
Frequency
Treatment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Name for ear discharge

A

Otorrhea

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What do we note about ear discharge?

A 
If there is any
Color
Consistency
Odor
Any relationship between discharge and ear pain?
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Subjective data we ask about hearing loss

A

Onset
Character
Situational

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What can we see in our patient that may indicate hearing loss

A 
Shouting
Hollow sounds
If they do a lot of airplane travel
Family history of hearing loss
Devices
Coping strategies (tv up loud, etc.)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

If pt does have hearing loss, what should we note about pt?

A 
Lip reading
Frowning or straining
Posturing (turning head)
Does not answer appropriately (says huh?)
Irritable or startled
Inappropriately loud voice
Tone flat
Television volume increasing
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What do we ask patient about environmental exposure?

A 
Any exposure to loud noises?
Machinery
Gunshots
If they use ear protection
*document occupation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Name for ringing of ears (spelling)

A

Tinnitus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What do we ask patient about ringing of ears

A

Onset
Occurrence
Amplification

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Name for dizziness

A

Vertigo

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What do we ask patient about dizziness

A

Onset
Associated factors
Alleviating factors
Has it happened before

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What do we ask patient about self-care

A

Cleaning (do they use q-tips?)
Last exam
Devices

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Characteristics of wet cerumen

A

Honey brown to dark brown
Moist
(Most common in African Americans)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Characteristics of dry cerumen

A

Gray
Flaky
Usually forms thin mass
(Most common in Asians)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Name for ear exam

A

Otoscopic exam

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Difference between doing an otoscopic exam on an adult vs. a child

A

Adult - pull pinna up and back

Child - pull pinna down and back

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

What is the goal of an otoscopic exam?

A

Visualize tympanic membrane

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

What do we look at during inspection and palpation of external ear?

A
  • Position upright/eye level?
  • Size and shape (equal size, skin intact)
  • Tenderness
  • External auditory meatus (size of opening, no pain, tenderness, or erythema)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

How do we assess if pt has tenderness?

A

Move pinna and push tragus
Should be firm and pain free
(If pain, could be swimmer’s ear)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

What do we note while using the otoscope to examine?

A
  • Redness or swelling
  • Lesions or foreign bodies
  • Discharge (color and odor)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

What should the color of the tympanic membrane look like?

A
  • Shiny and translucent
  • Pearl gray color
  • Cone-shaped light reflex prominent
36
Q

What should the integrity of the tympanic membrane look like?

A

Should be intact

Scarring is indicative of repeated ear infections

37
Q

What should the position of the tympanic membrane look like?

A

Flat

Slightly pulled in at center

38
Q

What is the name for a middle ear infection

A

Otitis media

39
Q

What is a middle ear infection?

A

Obstruction of Eustachian tube (doesn’t drain)

40
Q

Geographically, where are middle ear infections most common?

A

North America

New Zeland

41
Q

Group of people who most commonly get middle ear infections

A

Children

42
Q

How are middle ear infections treated?

A

Multiple antibiotics prescribed

Can lead to antibiotic resistance - superbugs

43
Q

Most common side effect of middle ear infections

A
  • residual fluid in middle ear (post treatment)
  • potential hearing impairment
  • cognitive delay
44
Q

Parental considerations about otitis media

A

Position is important

  • Partly upright while feeding
  • Do not prop bottle or let baby take bottle to bed
  • Encourage breastfeeding
45
Q

Name for swimmer’s ear

A

Otitis externa

46
Q

How to perform the whispered voice test

A 
One ear at a time while masking hearing in other ear
Shield your lips
Head 1-2 ft away
Whisper slowly
2 syllable words

Normal: repeat of each word

47
Q

What is the pupillary light reflex?

A

Normal constriction of pupils when bright light shines on retina

48
Q

What is fixation?

A

A reflex direction of eye toward and object attracting person’s attention

49
Q

Adaption of eye for near vision (Spelling)

A

Accommodation

50
Q

What is accommodation?

A

Adaptation of eye for near vision

51
Q

Medical term for cross eye?

A

Strabismus

52
Q

Medical term for double vision

A

Diplopia

53
Q

Self care behaviors to ask pt about eyes

A

Wear eye protection at work if welder, construction, etc.?
Take any eye medications?
Smoke?
Have you experienced any vision loss? How do you cope?

54
Q

What position should pt be in to collect objective data about eyes?

A
  • Standing for vision screening

- Sitting up with head at eye level

55
Q

Equipment needed to collect objective data about pt’s eyes

A
  • Snellen eye chart
  • Handheld visual screener (used to occlude also)
  • Penlight
56
Q

How to perform far vision test

A
  • Snellen eye chart
  • Place chart in well-lit spot at eye level
  • Pt stants 20 ft from chart
  • Pt uses opaque card to shield one eye at a time during test
  • Pt leaves on glasses/contacts
  • Start with smallest lines
57
Q

How to perform near vision test

A
  • Use visual screener
  • Hold card 14 inches away
  • Distance equals 20/20 on Snellen
  • Test each eye seperately
  • Normal result is 14/14 bilateral
58
Q

Test used to test pt’s peripheral vision

A

Confrontation test

59
Q

How to perform the confrontation test

A
  • Stand 2 ft away from pt
  • Pt covers one eye
  • Examiner covers opposite eye
  • Use object and slowly advance from periphery in several directions
  • Repeat for opposite eye
  • Pt should see object at the same time as examiner
  • Normal; Peripheral vision intact
60
Q

Test used to examin pt’s corneal light reflex

A

Hirschberg test

61
Q

What does the Hirschberg test do?

A

Assesses strength of eye muscles

62
Q

How to perform the Hirschberg test

A
  • Pt stares straight ahead
  • Hold light 12 inches away
  • Note reflection of light on corneas
  • Reflection should be in same spot on each eye
63
Q

Eye turned inward

A

Estropia

64
Q

Eye turned outward

A

Exotropia

65
Q

Eye turned upward

A

Hypertropia

66
Q

Eye turned downward

A

Hypotropia

67
Q

How to detect weakness in a particular eye

A

Cover test

68
Q

What does the cover test test?

A

Detects weakness in a particular eye

Extraocular muscle function

69
Q

How to perform the cover test

A

Pt stares straight ahead
Covers one eye at a time
Note uncovered eye
Normal response is a steady fixed gaze

70
Q

What does the diagnostic positions test test?

A

Extraocular muscle function

71
Q

How to perform the diagnostic positions test

A

Examiner guides patient
Object held at 12 inches
Patient to follow examiner movement with eyes only
Goal: Parallel tracking with both eyes

72
Q

What do we look at when inspecting the patient’s eyebrows?

A

Symmetrical, present bilaterally

Moves with expression changes

73
Q

What do we look at when we inspect a patient’s conjunctiva/sclera

A

Conjunctiva clear
Sclera china white
African Americans may have fatty deposits (normal)

74
Q

What do we look at when we inspect a pt’s eyelids and lashes?

A

Normal overlap

Eyelashes are evenly distributed

75
Q

What do we look at when inspecting a pt’s lacrimal apparatus?

A

No pain
Normal tears
Pushing on lacrimal apparatus shouldn’t produce tears

76
Q

What do we note about the pt’s pupillary light reflex?

A

Size/shape
Normally pupils appear round, regular, and of equal size

(PERRLA)

77
Q

What can we use to help us to remember what we should pay attention to when examining a pt’s pupils?

A

PERRLA (Pupils are Equal, Round, React to Light and Accommodation

78
Q

How should you examine a patient’s pupil constriction?

How to document if it’s normal

A

Side to side comparison with pen light
Person gazes at a distance

Normal: direct and consensual constriction

79
Q

How to test a pt’s accommodation

A

Person focuses on distant object
They shift gaze with your finger
For near and far vision
You look to see if their pupils constrict/dilate appropriately

80
Q

What happens to someone’s pupils when using far vision?

A

Pupils dilate

81
Q

What happens to someone’s vision when using near vision?

A

Pupils constrict

82
Q

How to document normal pupillary response?

A

PERRLA

83
Q

What does PERRLA stand for?

A 
Pupils
Equal
Round
Reactive to 
Light and
Accommodation
84
Q

What do we look at when inspecting occular fundus?

A

Red reflex

85
Q

What do you use when inspecting ocular fundus?

A

Ophthalmoscope

86
Q

What should pt’s pupils look like when examining with an ophthalmoscope?

A

Should see a flash of orange with red vessels

Health Assessment (17 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions